Concordance Between Self-Reported Visual Difficulty and Objective Visual Impairment: The National Health and Aging Trends Study.

OBJECTIVE: To examine the performance of self-reported visual difficulty (VD) in predicting objective visual impairment (VI) in older adults and explore factors that influence discordance in these classifications. DESIGN: Cross-sectional analysis of the National Health and Aging Trends Study (2022). METHODS: Participants reporting blindness or difficulties with distance or near vision were characterized as having VD. Presenting binocular distance visual acuity (VA), near VA, and contrast sensitivity (CS) were assessed. Objective VI was defined as having VI in either distance VA (worse than 20/40), near VA (worse than 20/40), or CS (worse than 1.55 logCS). Receiver operating characteristic analysis was used to compare performance of VD in predicting objective VI. To investigate factors that influence discordance, we limited our sample to adults with objective VI and employed a multivariable logistic regression model to identify factors associated with not reporting VD. Similar analyses were performed to explore factors associated with reporting VD in adults without objective VI. RESULTS: 4,999 adults were included in the 2022 cohort. VD achieved an area under the curve (AUC) of 56.0 (95% CI: 55.2, 56.9) in predicting objective VI, with a sensitivity of 15.8 (95% CI: 14.2, 17.5) and specificity of 96.3 (95% CI: 95.5, 96.9). Characteristics associated with not reporting VD in adults with objective VI included: female gender (odds ratio [OR]: 0.64 [95% CI: 0.42, 0.99]), Hispanic ethnicity (OR: 0.49 [95% CI: 0.31, 0.78), higher income (≥75k, OR: 1.99 [95% CI: 1.14, 3.45]), having ≥4 comorbidities (OR: 0.46 [95% CI: 0.29, 0.72]), and having depressive symptoms (OR: 0.49 [95% CI: 0.25, 0.93]). Meanwhile, factors associated with self-reporting VD in the absence of objective VI included Hispanic ethnicity (OR: 2.11 [95% CI: 1.15, 3.86]), higher income (≥75k, OR: 0.27 [95% CI: 0.12, 0.63]), and having anxiety symptoms (OR: 3.05 [95% CI: 1.56, 5.97]). CONCLUSIONS: Self-reported visual difficulty is a distinct measure assessing disability and has limited ability in predicting objective VI. Caution is advised when utilizing self-reported visual difficulty as a surrogate measure for objective VI in epidemiological studies, though it may still be an effective way to capture risk of current or future disability.

Digital Technology Use Among Older Adults With Vision Impairment.

Importance: Telehealth has the potential to improve health for older adults, but many access disparities exist, including for those with vision impairment (VI). Objective: To examine the associations between VI and digital technology access measures in US older adults. Design, Setting, and Participants: This was a cross-sectional study that included Medicare beneficiaries 65 years and older. Beneficiary data were obtained from the National Health and Aging Trends Study (NHATS) 2021; data collection was conducted from June 2020 through January 2021. Data were analyzed September 2023. Exposure: VI, measured on categorical (distance and near VI [>0.30 logMAR], contrast sensitivity impairment [CSI; <1.55 logCS], and any VI [distance VI, near VI, or CSI]), and continuous (distance and near acuity [logMAR] and contrast sensitivity [logCS]) scales. Main Outcomes: Self-reported outcomes of digital technology access from the technological environment component of the NHATS. Results: Of the 2822 Medicare beneficiaries (mean [SD] age, 78.5 [5.6] years; 1605 female [54.7%]) included in this study, patients self-identified with the following race and ethnicity categories (weighted percentages): 575 non-Hispanic Black (8.0%), 132 Hispanic (7.0%), 2019 non-Hispanic White (81.7%), and 63 non-Hispanic other race (3.4%), which included American Indian, Alaska Native, Asian, multiracial, Native Hawaiian, Pacific Islander, or other specified race. A total of 1077 of 2822 patients (32.3%) had any VI. In multivariable logistic regression models, older adults with any VI had lower odds of having or knowing how to use a cellphone (odds ratio [OR], 0.58; 95% CI, 0.38-0.88), computer (OR, 0.61; 95% CI, 0.47-0.79), or tablet (OR, 0.68, 95% CI = 0.54-0.85) than peers without VI. In other models, near VI was associated with lower odds of having and knowing how to use a phone (OR, 0.56; 95% CI, 0.36-0.87), computer (OR, 0.57; 95% CI, 0.44-0.75), or tablet (OR, 0.65; 95% CI, 0.52-0.81) compared with no near VI. CSI was associated with lower odds of having and knowing how to use a phone (OR, 0.66; 95% CI, 0.45-0.99) or computer (OR, 0.72; 95% CI, 0.55-0.93) compared with no CSI. Distance VI was only associated with lower odds of having and knowing how to use a cellphone (OR, 0.63; 95% CI, 0.41-0.95). Any VI and individual categorical VI measures were not associated with other outcomes of digital health- and nonhealth-related experiences. Similar associations were noted when vision was examined on a continuous scale. However, worse distance acuity (per 0.1 logMAR) was associated with being less likely to visit with family or friends on a video call (OR, 0.91; 95% CI, 0.84-0.98) and to order or refill prescriptions online (OR, 0.90; 95% CI, 0.83-0.97). Conclusions and Relevance: Results suggest that older US adults with VI were less likely to have access to digital technology than peers without VI, although no differences were noted in the report of digital health- and nonhealth-related activities. These findings highlight the potential for inequities that may arise in telehealth for older adults with VI and the necessity to develop strategies to improve accessibility of telemedicine for all.

COVID-19 Testing and Vaccination Among US Older Adults with Vision Impairment: The National Health and Aging Trends Study 2021.

PURPOSE: To examine the associations between vision impairment (VI) and COVID-19 testing and vaccination services in older US adults. METHODS: This cross-sectional study assessed data from adults ≥ 65 years who participated in the National Health and Aging Trends Study (year 2021), a nationally representative sample of Medicare beneficiaries. Exposure: Distance VI (<20/40), near VI (<20/40), contrast sensitivity impairment (CSI) (<1.55 logCS), and any VI (distance, near, or CSI). Outcomes: Self-reported COVID-19 testing and vaccination. RESULTS: Of 2,822 older adults, the majority were female (weighted; 55%) and White (82%), and 32% had any VI. In fully-adjusted regression analyses, older adults with any VI had similar COVID-19 vaccination rates to adults without any VI (OR:0.77, 95% CI:0.54-1.09), but had lower odds of COVID-19 testing (OR:0.82, 95% CI:0.68-0.97). Older adults with distance (OR:0.47, 95% CI:0.22-0.99) and near (OR:0.68, 95% CI:0.47-0.99) VI were less likely to be vaccinated for COVID-19, while those with CSI were less likely to test for COVID-19 (OR:0.76, 95% CI:0.61-0.95), as compared to peers without respective impairments. The remaining associations were not significant (p > .05). CONCLUSIONS AND RELEVANCE: These findings highlight inequities in the COVID-19 pandemic response for people with vision disability and emphasize the need for equitable prioritization of accessibility of healthcare services for all Americans.

Longitudinal Changes in Visual Acuity and Contrast Sensitivity and Incident Dementia.

PURPOSE: To evaluate the impact of baseline and change in vision on the risk of developing dementia. DESIGN: Retrospective cohort study. METHODS: This longitudinal analysis utilized data from the 2021 and 2022 National Health and Aging Trends Study. Binocular presenting vision was assessed, including distance (DVA) and near (NVA) visual acuity, and contrast sensitivity (CS). Dementia status was defined based on: 1) medical diagnosis of dementia, 2) dementia score, or 3) poor cognitive test performance. RESULTS: Of the 2,159 adults included in this study, weighted mean (SD) age was 77.9 years (5.2), with the majority being female (weighted: 54%), and White (88%). The baseline median (interquartile range [IQR]) DVA was 0.08 (0-0.20) logMAR, NVA was 0.17 (0.09-0.26) logMAR, and CS was 1.80 (1.65-1.85) logCS. Over the 1-year follow up period, 192 (6.6%) adults developed dementia. In time-to-event analyses, baseline DVA (HR: 1.08 [95% CI: 1.02-1.14], per 0.1 logMAR), NVA (HR: 1.07 [95% CI: 1.01-1.13], per 0.1 logMAR), and CS (HR: 1.09 [95% CI: 1.03-1.15], per 0.1 logCS) were associated with greater likelihood of incident dementia. Further, change in CS (HR: 1.14 [95% CI: 1.04-1.25], per 0.1 logCS worse/year), but not VA, was associated with greater likelihood of incident dementia. CONCLUSIONS: Worse baseline VA and CS are associated with greater likelihood of incident dementia. Further, worsening CS over time, but not VA, was associated with higher likelihood of incident dementia. Future work is needed to study interventions targeted at improving vision deficits and examine their impact on decreasing dementia risk.

The Impact of Social Vulnerability on Structural and Functional Glaucoma Severity, Worsening, and Variability.

PURPOSE: To determine the associations between social vulnerability index (SVI) and baseline severity, worsening, and variability of glaucoma, as assessed by visual field (VF) and OCT. DESIGN: Retrospective longitudinal cohort study. PARTICIPANTS: Adults with glaucoma or glaucoma suspect status in 1 or both eyes. Visual fields were derived from 7897 eyes from 4482 patients, while OCTs were derived from 6271 eyes from 3976 patients. All eyes had a minimum of 5 tests over follow-up using either the Humphrey Field Analyzer or the Cirrus HD-OCT. METHODS: Social vulnerability index, which measures neighborhood-level environmental factors, was linked to patients' addresses at the census tract level. Rates of change in mean deviation (MD) and retinal nerve fiber layer (RNFL) thickness were computed using linear regression. The slope of the regression line was used to assess worsening, while the standard deviation of residuals was used as a measure of variability. Multivariable linear mixed-effects models were used to investigate the impact of SVI on baseline, worsening, and variability in both MD and RNFL. We further explored the interaction effect of mean intraocular pressure (IOP) and SVI on worsening in MD and RNFL. MAIN OUTCOME MEASURES: Glaucoma severity defined based on baseline MD and RNFL thickness. Worsening defined as MD and RNFL slope. Variability defined as the standard deviation of the residuals obtained from MD and RNFL slopes. RESULTS: Increased (worse) SVI was significantly associated with worse baseline MD (ß = -1.07 dB, 95% confidence interval [CI]: [-1.54, -0.60]), thicker baseline RNFL (ß = 2.46 µm, 95% CI: [0.75, 4.17]), greater rates of RNFL loss (ß = -0.12 µm, 95% CI: [-0.23, -0.02]), and greater VF variability (ß = 0.16 dB, 95% CI: [0.07, 0.24]). Having worse SVI was associated with worse RNFL loss with increases in IOP (ßinteraction = -0.07, 95% CI: [-0.12, -0.02]). CONCLUSIONS: Increased SVI score is associated with worse functional (VF) loss at baseline, higher rates of structural (OCT) worsening over time, higher VF variability, and a greater effect of IOP on RNFL loss. Further studies are needed to enhance our understanding of these relationships and establish their cause. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Vision Impairment and Psychosocial Function in US Adults.

Importance: Vision impairment and psychosocial function, including symptoms of depression and anxiety and social isolation, are a major cause of morbidity in the US. However, there is a lack of nationally representative studies assessing associations between both objective and subjective vision impairment with psychosocial function following the COVID-19 pandemic. Objective: To provide updated national estimates on the associations of vision impairment with depressive and anxiety symptoms and social isolation in US adults 65 years and older. Design, Setting, and Participants: This was a cross-sectional analysis of the National Health and Aging Trends Study round 9 (2019) and 11 (2021), a nationally representative sample of Medicare beneficiaries aged 65 years and older. Binocular distance visual acuity, near visual acuity, and contrast sensitivity were tested. Objectively measured vision impairment was defined as having vision impairment in either distance visual acuity (worse than 20/40), near visual acuity (worse than 20/40), or contrast sensitivity (worse than 1.55 logCS). Self-reported vision impairment was defined based on participants' report on their vision status. Data were analyzed in May 2023. Main Outcomes and Measures: Depressive and anxiety symptoms assessed via the Patient Health Questionnaire. Social isolation was defined based on living arrangement, communication frequency, and activity participation responses. Results: Among 2822 community-dwelling adults sampled from a population of 26 182 090, the mean (SD) age was 78.5 (5.6) years; 1605 individuals (54.7%) were female; 1077 (32.3%) had objectively measured vision impairment, and 203 (6.4%) had self-reported vision impairment. In adjusted models, all outcomes were significantly associated with objectively measured vision impairment, including depressive symptoms (odds ratio [OR], 1.81; 95% CI, 1.26-2.58), anxiety symptoms (OR, 1.74; 95% CI, 1.13-2.67), and severe social isolation (OR, 2.01; 95% CI, 1.05-3.87). Similarly, depressive symptoms (OR, 2.37; 95% CI, 1.44-3.88) and anxiety symptoms (OR, 2.10; 95% CI, 1.09-4.05) but not severe social isolation symptoms (OR, 2.07; 95% CI, 0.78-5.49) were significantly associated with self-reported vision impairment. Conclusions and Relevance: In this study, vision impairment was associated with several psychosocial outcomes, including symptoms of depression and anxiety and social isolation. These findings provide evidence to support prioritizing research aimed at enhancing the health and inclusion of people with vision impairment.

The Quantitative Impact of Visual Function on Accelerometer-measured Physical Activity in Older United States Adults: A Nationwide Cross-sectional Analysis.

Purpose: To explore the impact of objective vision measures on novel metrics of objectively-measured physical activity (PA) in a nationally representative sample of United States (US) older adults. Design: Cross-sectional analysis using data from the National Health and Aging Trends Study. Participants: Adults had their distance and near visual acuity (VA) and contrast sensitivity (CS) tested. Any objective vision impairment (VI), defined as any VI in distance VA, near VA, or CS, was the primary exposure. Physical activity data were collected using the Actigraph CentrePoint Insight Watch worn for 7 days. Methods: Multivariable regression models were used to investigate the association between vision and PA measures. All analyses accounted for the survey design and models were adjusted for age, sex, race, living arrangement, education, and comorbidities. Main Outcome Measures: Physical activity metrics included (1) total daily activity (active minutes per day, number of active bouts, and mean length of active bouts), (2) activity fragmentation, and (3) time until 75% activity. An active bout was defined as ≥ 1 consecutive active minute. Activity fragmentation was defined as the probability of an active minute being followed by a sedentary minute, with higher values indicating more fragmented activity. Time until 75% activity was defined as the time taken to complete 75% of daily PA starting from their first active bout. Results: Among 723 participants, sampled from 10 443 338 older adults in the US, 30% had any objective VI. Any objective VI was significantly associated with lower number of active minutes per day (7.8% fewer [95% confidence interval {CI}: -13.6% to -1.7%]), shorter active bouts (7.0% shorter [95% CI: -12.3% to -1.4%]), and greater activity fragmentation (2.5% [95% CI: 0.8% to 4.2%]), while no associations were found with number of active bouts. Time until 75% activity did not significantly differ between adults with any objective VI and those without (P = 0.34). Conclusions: Older US adults with any objective VI displayed lower total daily activity, as well as more fragmented, shorter periods of PA, despite having a similar number of active bouts compared to their normally sighted counterparts. Implementing interventions that increase bout duration may help promote PA in adults with VI. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Vision impairment and food insecurity in the national health and aging trends study.

Introduction: Vision impairment (VI) may further exacerbate older adults' vulnerability to experiencing food insecurity and may be a unique and important target for policies addressing access to nutritional food. The purpose of this study is to determine the association of VI in older adults with food insecurity. Methods: This is a cross-sectional analysis of round 11 (2021) of the National Health and Aging Trends Study (NHATS), a nationally representative survey of U.S. Medicare beneficiaries ages 65 and older. Participants include 2,815 older adults with complete data on at least one objective measure of vision (distance, near or contrast sensitivity) and food insecurity. Food insecurity was assessed using a previously developed indicator of food insecurity in NHATS. VI was defined as binocular visual acuity (VA) worse than 0.3 logMAR (Snellen equivalent 20/40) at distance or its near equivalent, or contrast sensitivity (CS) worse than 1.55 logUnits. Continuous VI measures included distance and near VA (per 0.1 logMAR), and CS (per 0.1 logCS). Results: Participants were majority White (82%) and female (55%), and 3% had food insecurity. Older adults with any VI had a greater prevalence of food insecurity than adults without VI (5.0% vs. 2.0%, p < 0.05). In fully adjusted regression analyses, individuals with any VI experienced double the odds of food insecurity than individuals without VI (OR: 2.1, 95% CI: 1.2-3.6). Distance VI (measured continuously) was associated with 1.2 times the odds of food insecurity (OR = 1.2; 95% CI: 1.0-1.3, per 0.1 logMAR). All other vision measures trended towards higher odds of food insecurity, though not statistically significant. Discussion: Older adults with VI experience higher rates of food insecurity than their peers. Interventions to improve food security should be targeted towards addressing the specific barriers faced by visually impaired older adults.

Retinal Imaging Findings in Inherited Retinal Diseases.

Inherited retinal diseases (IRDs) represent one of the major causes of progressive and irreversible vision loss in the working-age population. Over the last few decades, advances in retinal imaging have allowed for an improvement in the phenotypic characterization of this group of diseases and have facilitated phenotype-to-genotype correlation studies. As a result, the number of clinical trials targeting IRDs has steadily increased, and commensurate to this, the need for novel reproducible outcome measures and endpoints has grown. This review aims to summarize and describe the clinical presentation, characteristic imaging findings, and imaging endpoint measures that are being used in clinical research on IRDs. For the purpose of this review, IRDs have been divided into four categories: (1) panretinal pigmentary retinopathies affecting rods or cones; (2) macular dystrophies; (3) stationary conditions; (4) hereditary vitreoretinopathies.

Acquired Vitelliform Lesions in Intermediate Age-Related Macular Degeneration: A Cross Sectional Study.

PURPOSE: This study aims to define the characteristics of acquired vitelliform lesions (AVLs) in patients with intermediate age-related macular degeneration (iAMD). DESIGN: Retrospective, observational, cross sectional study. SUBJECTS: This study included 217 eyes with AVLs associated with iAMD, and an equivalent number of control patients. METHODS: OCT scans were evaluated for qualitative and quantitative parameters at both the eye and lesion level. Eye-level parameters included the presence of: hyporeflective core drusen, intraretinal hyperreflective foci (IHRF), subretinal drusenoid deposits, macular pachyvessels, central retinal thickness, and central choroidal thickness. Lesion-level qualitative parameters included the presence of ellipsoid zone (EZ) and external limiting membrane disruption overlying the AVL, IHRF overlying the AVL, AVL overlying drusen, pachyvessels under the AVL, a solid core within AVL, and AVL location. Lesion-level quantitative characteristics included AVL height and width, AVL distance from the fovea, and sub-AVL choroidal thickness. MAIN OUTCOME MEASURES: The primary outcomes assessed included the frequency of IHRF, the presence of macular pachyvessels, central choroidal thickness, and the dimensions (both height and width) of AVLs. RESULTS: Comparing the AVL and control groups, the frequency of IHRF (AVL: 49.3% vs. control: 26.3%) and macular pachyvessels (37.3% vs. 6.9%) was significantly higher in the AVL case group, and the central choroidal thickness (256.8 ± 88 µm vs. 207.1± 45 µm) was thicker in the AVL group. Acquired vitelliform lesions located over drusen, with overlying IHRF, or situated subfoveally, and AVL lesions with EZ disruption were found to have a greater lesion height and width compared with AVL lesions lacking these characteristics (P value < 0.001 for all). Additionally, a significant negative correlation was observed between the distance from the fovea and AVL height (Spearman rho: -0.19, P = 0.002) and width (Spearman rho: -0.30, P = 0.001). CONCLUSIONS: This study represents the largest reported cohort of AVL lesions associated with iAMD. Novel findings include the higher frequency of pachyvessels in addition to the presence of a thicker choroid in these eyes, as well as the greater height and width of AVL closer to the foveal center. These findings may offer insights into pathophysiologic mechanisms underlying the development of AVL. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Predictive Factors Influencing the Evolution of Acquired Vitelliform Lesions in Intermediate Age-Related Macular Degeneration Eyes.

PURPOSE: In this study, we identify risk factors that predict the progression of acquired vitelliform lesions (AVLs) over time. DESIGN: Retrospective cohort study. SUBJECTS: One hundred sixty-three eyes of 132 patients with a diagnosis of intermediate age-related macular degeneration (iAMD) with AVL. METHODS: This retrospective study evaluated consecutive eyes with AMD from a retina clinic population and included 1181 patients and 2362 eyes. After excluding cases with associated geographic atrophy, macular neovascularization (MNV), vitreomacular traction, and those with <2 years of follow-up data, the final analysis cohort consisted of 163 eyes (132 patients) with ≥1 AVL. The first available visit in which an AVL was evident was considered the baseline visit, and follow-up data were collected from a visit 2 years (± 3 months) later. Progression outcomes at the follow-up visit were classified into 6 categories: resorbed, collapsed, MNV, stable, increasing, and decreasing. Subsequently, we analyzed the baseline characteristics for each category and calculated odds ratios (ORs) to predict these various outcomes. MAIN OUTCOME MEASURES: The study focused on identifying predictive factors influencing the evolution of AVL in iAMD eyes. RESULTS: In total, 163 eyes with AVL had follow-up data at 2 years. The collapsed group demonstrated a significantly greater baseline AVL height and width compared with other groups (P < 0.001). With regard to qualitative parameters, subretinal drusenoid deposits (SDDs) and intraretinal hyperreflective foci (IHRF) at the eye level, AVL located over drusen, and IHRF and external limiting membrane disruption over AVL were significantly more prevalent in the collapsed group compared with other groups (P < 0.05 for all comparisons). Odds ratios for progressing to atrophy after 2 years of follow-up, compared with the resorbed group, were significant for SDD (OR, 2.82; P = 0.048) and AVL height (OR, 1.016; P = 0.006). CONCLUSIONS: The presence of SDDs and greater AVL height significantly increases the risk of developing atrophy at the location of AVL after 2 years of follow-up. These findings may be of value in risk prognostication and defining patient populations for inclusion in future early intervention trials aimed at preventing progression to atrophy. FINANCIAL DISCLOSURES: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Using Objective Vision Measures to Explore the Association of Vision Impairment With Cognition Among Older Adults in the United States.

PURPOSE: To evaluate the association between vision impairment (VI) and cognitive function using objective measures. DESIGN: Cross-sectional analysis with a nationally representative sample. METHODS: The association between VI and dementia was investigated in a US population-based, nationally representative sample of Medicare beneficiaries, the National Health and Aging Trends Study (NHATS), a nationally representative sample of Medicare beneficiaries aged ≥65 years, using objective vision measures. Exposures included distance VI (>20/40), near VI (>20/40), contrast sensitivity impairment (CSI) (<1.55), any objective VI (distance and near visual acuity, or contrast), and self-reported VI. The main outcome measure was dementia status defined based on survey reports, interviews, and cognitive tests. RESULTS: A total of 3026 adults were included in this study; the majority were female (55%) and White (82%). The weighted prevalence rates were 10% for distance VI, 22% for near VI, 22% for CSI, 34% for any objective VI, and 7% for self-reported VI. Across all measures of VI, dementia was more than twice as prevalent in adults with VI compared to their peers without (P < .001 for all). In adjusted models, all measures of VI were associated with higher odds of dementia (distance VI: OR 1.74, 95% CI 1.24-2.44; near VI: OR 1.68, 95% CI 1.29-2.18; CSI: OR 1.95, 95% CI 1.45-2.62; any objective VI: OR 1.83, 95% CI 1.43-2.35; self-reported VI: OR 1.86, 95% CI 1.20-2.89). CONCLUSIONS: In a nationally representative sample of older US adults, VI was associated with increased odds of dementia. These results suggest that maintaining good vision and eye health may help preserve cognitive function in older age, although more research is needed to investigate the potential benefits of interventions that focus on vision and eye health on cognitive outcomes.

Culturally Adapting a Digital Intervention to Reduce Suicidal Ideation for Syrian Asylum Seekers and Refugees in the United Kingdom: Protocol for a Qualitative Study.

BACKGROUND: The conflict in Syria has produced the largest forced displacement crisis since the Second World War. As a result, Syrians have experienced various stressors across the migratory process, putting them at an increased risk of developing mental health issues, including, crucially, suicidal ideation (SI). Despite their high rates of SI across Europe, there remain various barriers to accessing treatment. One way to increase access is the use of culturally adapted digital interventions, which have already shown potential for other minority populations. To culturally adapt the intervention, further research is needed to better understand Syrian asylum seekers' and refugees' cultural conceptualizations, coping strategies, and help-seeking behavior for SI. To do so, this study will use a unique cultural adaptation framework to intervene at points of lived experience with the migratory process where Syrian culture and signs of psychopathology converge. Likewise, co-design events will be used to adapt points of experience with the intervention where Syrian culture and the intervention conflict. As the first cultural adaption of a digital SI intervention for Syrian asylum seekers and refugees, this study will hopefully encourage further development of culturally sensitive interventions for the largest refugee population in the United Kingdom and the world. OBJECTIVE: The objective of the study is to increase access to mental health treatment for Syrian asylum seekers and refugees in the United Kingdom by culturally adapting a digital intervention to reduce SI. METHODS: The study will use experience-based co-design, an action research method, to culturally adapt a digital intervention to reduce SI for Syrian asylum seekers and refugees in the United Kingdom. This will involve conducting 20-30 interviews to understand their lived experiences with the migratory process, cultural conceptualizations of mental health and SI, coping strategies, mental health help-seeking behavior, and perceptions of digital mental health interventions. In addition, 3 co-design events with 6 participants in each will be held to collaboratively adapt the intervention. Touchpoints and themes extracted from each phase will be prioritized by a community panel before adapting the intervention. RESULTS: The study began in November 2022 and will continue until the last co-design event in August 2023. The results of the study will then be published by December 2023. CONCLUSIONS: Access to treatment for some of the most severe mental health issues is still limited for Syrian asylum seekers and refugees in the United Kingdom. Cultural adaptations of digital interventions developed for general populations have the potential to increase access to treatment for this population. Specifically, adapting the intervention for Syrian asylum seekers' and refugees' experiences with SI in relation to their lived experience with the migratory process may enable greater recruitment and adherence for users of various cultural and ethnic subgroups and levels of SI. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/47627.

SLIViT: a general AI framework for clinical-feature diagnosis from limited 3D biomedical-imaging data.

We present SLIViT, a deep-learning framework that accurately measures disease-related risk factors in volumetric biomedical imaging, such as magnetic resonance imaging (MRI) scans, optical coherence tomography (OCT) scans, and ultrasound videos. To evaluate SLIViT, we applied it to five different datasets of these three different data modalities tackling seven learning tasks (including both classification and regression) and found that it consistently and significantly outperforms domain-specific state-of-the-art models, typically improving performance (ROC AUC or correlation) by 0.1-0.4. Notably, compared to existing approaches, SLIViT can be applied even when only a small number of annotated training samples is available, which is often a constraint in medical applications. When trained on less than 700 annotated volumes, SLIViT obtained accuracy comparable to trained clinical specialists while reducing annotation time by a factor of 5,000 demonstrating its utility to automate and expedite ongoing research and other practical clinical scenarios.

Estimating mortality and disability in Peru before the COVID-19 pandemic: a systematic analysis from the Global Burden of the Disease Study 2019.

Background: Estimating and analyzing trends and patterns of health loss are essential to promote efficient resource allocation and improve Peru's healthcare system performance. Methods: Using estimates from the Global Burden of Disease (GBD), Injuries, and Risk Factors Study (2019), we assessed mortality and disability in Peru from 1990 to 2019. We report demographic and epidemiologic trends in terms of population, life expectancy at birth (LE), mortality, incidence, prevalence, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) caused by the major diseases and risk factors in Peru. Finally, we compared Peru with 16 countries in the Latin American (LA) region. Results: The Peruvian population reached 33.9 million inhabitants (49.9% women) in 2019. From 1990 to 2019, LE at birth increased from 69.2 (95% uncertainty interval 67.8-70.3) to 80.3 (77.2-83.2) years. This increase was driven by the decline in under-5 mortality (-80.7%) and mortality from infectious diseases in older age groups (+60 years old). The number of DALYs in 1990 was 9.2 million (8.5-10.1) and reached 7.5 million (6.1-9.0) in 2019. The proportion of DALYs due to non-communicable diseases (NCDs) increased from 38.2% in 1990 to 67.9% in 2019. The all-ages and age-standardized DALYs rates and YLLs rates decreased, but YLDs rates remained constant. In 2019, the leading causes of DALYs were neonatal disorders, lower respiratory infections (LRIs), ischemic heart disease, road injuries, and low back pain. The leading risk factors associated with DALYs in 2019 were undernutrition, high body mass index, high fasting plasma glucose, and air pollution. Before the COVID-19 pandemic, Peru experienced one of the highest LRIs-DALYs rates in the LA region. Conclusion: In the last three decades, Peru experienced significant improvements in LE and child survival and an increase in the burden of NCDs and associated disability. The Peruvian healthcare system must be redesigned to respond to this epidemiological transition. The new design should aim to reduce premature deaths and maintain healthy longevity, focusing on effective coverage and treatment of NCDs and reducing and managing the related disability.